Lies you were told in Med School (and Residency) Part 1 (of many) by Michael Heller, M.D.
Thursday, July 9, 2009 
Michael Heller, M.D.Let’s talk about “compliance”. Now, I’m not talking about following the mandates of some dumb-ass agency (that’s another day) but the idea that we should try to maximize patient compliance with their medication regimens. The dogma is that by giving them a regimen they can easily do, they will feel better sooner and maybe get better more often. This notion is just wrong, especially in the field of Emergency Medicine, where we are treating things that are symptomatic (like pain or itch) and not chronic conditions (like hypertension) that don’t cause symptoms.
So the patient has back pain. Maybe he sprained it, maybe he has a disc; it doesn’t matter. The natural history of this condition is that it will get better-or at least start to get better- in days to a week or so. It will not be better in the morning, however. If we were to believe the dogma, we would give him a long –acting non-steroidal, maybe Dolobid (2x/day) or Feldene (1 per day), some muscle relaxant, maybe Flexeril (2 or 3 times per day) and send him home, satisfied that we’ve given him a simple regimen of pills he can take only 2 or 3 times per day, at the most. I maintain this is all wrong.
This man’s back will get a little better with the long acting NSAID but you can be sure it’s going to hurt again in a few hours. Then he will have a bleak 8 or 16 hour future to look forward to without taking a pain pill. HE MIGHT EVEN COME BACK ON YOUR SHIFT! So be smart. Give him a complicated regimen of short acting pills something like this.
“Take 1 of these Ibuprofen 4 times during the day and one just before bed at night. Take one of these Flexeril (or Robaxin or whatever) 3 times per day but never take the 2 pills within 1 hour of each other (or you may die) and never take Flexeril within 45 minutes of meals and always eat some food within 30 minutes of taking Motrin”.
This crazy, impossible regimen is just what he needs. It will take days to work out (by which time the disease itself is getting better), and he never has more than a couple of hours before the next pill is due. This plan works best when the dosing schedules of the 2 drugs are relatively prime and even better when Fibonacci numbers are employed. If a third medicine is added to this regimen on a q 5h schedule, the number of ways the patient can take his medicines incorrectly approaches the number of electrons in the visible universe.
Compliance, Heller, Medical School in Pharmacology
Reader Comments (2)
Absolutely terrific. Certainly a contrarian view.
Rick
As is often the case, Mike's sarcastic humor identifies while at the same time hides a real problem: that we take very poor care of our patients, and have almost no knowledge of the consequences of our actions (mainly prescriptions). We develop bizarre prescrition habits without foundation or valid patient follow up.